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Wongtanasarasin W, Nishijima DK, Wood N, DeAngelis J, Storrow A, Schimmel J, Beltre N, Sacco D, Probst MA. Factors associated with incentive redemption among participants in a multicenter prospective syncope clinical study. Acad Emerg Med 2024. [PMID: 38940329 DOI: 10.1111/acem.14979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/15/2024] [Accepted: 06/18/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Wachira Wongtanasarasin
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Nancy Wood
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - John DeAngelis
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Alan Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan Schimmel
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Nataly Beltre
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - Dana Sacco
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - Marc A Probst
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York City, New York, USA
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Mirfazaelian H, Stiell I, Masoomi R, Garjani K, Thiruganasambandamoorthy V. Serious outcomes among emergency department patients with presyncope: A systematic review. Acad Emerg Med 2024. [PMID: 38853536 DOI: 10.1111/acem.14943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Syncope is transient loss of consciousness, and in presyncope, patients experience same prodromal symptoms without losing consciousness. While studies have extensively reported the risk of serious outcome among emergency department (ED) syncope, the outcome for patients with presyncope and their management are not well studied. We undertook a systematic review to assess the occurrence/identification of short-term (30-day) serious outcomes among ED patients with presyncope. METHODS ED studies that enrolled patients with presyncope and reported any short-term serious outcome were included. Studies that enrolled patients without presyncope (e.g., hypoglycemia, seizure, and stroke) were excluded. We restricted our study to only English publications and searched the MEDLINE, Embase, Scopus, and Web of Science from the inception date to July 2023. We used SIGN 50 tool for assessment of risk of bias. RESULTS In total, 1788 articles were screened by two reviewers and 32 articles were selected for full-text assessment. Five (four prospective and one retrospective) studies with 2741 presyncope patients were included. Four studies were from North America and the fifth one was from Europe. Included studies had weaknesses due to risk of bias, but all had acceptable quality. The prevalence of overall adverse outcome varied 4.4%-26.8% for all adults and 5.5%-18.7% among older patients; arrhythmia was the most prevalent (17.4% in one study), followed by anemia/hemorrhage as reported in different studies. Among older patients, myocardial infarction was the third most common serious outcome reported in one study. CONCLUSIONS The prevalence of short-term serious outcomes varies from 4% to 27% among ED patients with presyncope in our review, with arrhythmia being the most common serious outcome. Our review indicates that presyncope may carry a similar risk to syncope, and hence, the same level of caution should be exercised for ED presyncope management as syncope.
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Affiliation(s)
- Hadi Mirfazaelian
- Emergency Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ian Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Acure Care Research Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Khazar Garjani
- Emergency Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Acure Care Research Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Moore AB, Gershon C, Fiske C, Sun B, Nazer B, Kea B. Changes in Clinical Management Following 14-Day Ambulatory ECG Monitoring Following Emergency Department Evaluation for Unexplained Syncope. Ann Emerg Med 2024; 83:503-505. [PMID: 38276938 PMCID: PMC11066886 DOI: 10.1016/j.annemergmed.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 01/27/2024]
Affiliation(s)
- Andrew B Moore
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA.
| | - Colin Gershon
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - Christa Fiske
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - Benjamin Sun
- Department of Emergency Medicine, University of Pennsylvania Scholl of Medicine, Philadelphia, PA
| | - Babek Nazer
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA
| | - Bory Kea
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
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Wu S, Chen Z, Gao Y, Shu S, Chen F, Wu Y, Dai Y, Zhang S, Chen K. Development and Validation of a Novel Predictive Model for the Early Differentiation of Cardiac and Non-Cardiac Syncope. Int J Gen Med 2024; 17:841-853. [PMID: 38463438 PMCID: PMC10924787 DOI: 10.2147/ijgm.s454521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/26/2024] [Indexed: 03/12/2024] Open
Abstract
Background The diagnosis of cardiac syncope remains a challenge. This study sought to develop and validate a diagnostic model for the early identification of individuals likely to have a cardiac cause. Methods 877 syncope patients with a determined cause were retrospectively enrolled at a tertiary heart center. They were randomly divided into the training set and validation set at a 7:3 ratio. We analyzed the demographic information, medical history, laboratory tests, electrocardiogram, and echocardiogram by the least absolute shrinkage and selection operator (LASSO) regression for selection of key features. Then a multivariable logistic regression analysis was performed to identify independent predictors and construct a diagnostic model. The receiver operating characteristic curves, area under the curve (AUC), calibration curves, and decision curve analysis were used to evaluate the predictive accuracy and clinical value of this nomogram. Results Five independent predictors for cardiac syncope were selected: BMI (OR 1.088; 95% CI 1.022-1.158; P =0.008), chest symptoms preceding syncope (OR 5.251; 95% CI 3.326-8.288; P <0.001), logarithmic NT-proBNP (OR 1.463; 95% CI 1.240-1.727; P <0.001), left ventricular ejection fraction (OR 0.940; 95% CI 0.908-0.973; P <0.001), and abnormal electrocardiogram (OR 6.171; 95% CI 3.966-9.600; P <0.001). Subsequently, a nomogram based on a multivariate logistic regression model was developed and validated, yielding AUC of 0.873 (95% CI 0.845-0.902) and 0.856 (95% CI 0.809-0.903), respectively. The calibration curves showcased the nomogram's reasonable calibration, and the decision curve analysis demonstrated good clinical utility. Conclusion A diagnostic tool providing individualized probability predictions for cardiac syncope was developed and validated, which may potentially serve as an effective tool to facilitate early identification of such patients.
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Affiliation(s)
- Sijin Wu
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Zhongli Chen
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yuan Gao
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Songren Shu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Feng Chen
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Ying Wu
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yan Dai
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Shu Zhang
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Keping Chen
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
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Martone AM, Parrini I, Ciciarello F, Galluzzo V, Cacciatore S, Massaro C, Giordano R, Giani T, Landi G, Gulizia MM, Colivicchi F, Gabrielli D, Oliva F, Zuccalà G. Recent Advances and Future Directions in Syncope Management: A Comprehensive Narrative Review. J Clin Med 2024; 13:727. [PMID: 38337421 PMCID: PMC10856004 DOI: 10.3390/jcm13030727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/21/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
Syncope is a highly prevalent clinical condition characterized by a rapid, complete, and brief loss of consciousness, followed by full recovery caused by cerebral hypoperfusion. This symptom carries significance, as its potential underlying causes may involve the heart, blood pressure, or brain, leading to a spectrum of consequences, from sudden death to compromised quality of life. Various factors contribute to syncope, and adhering to a precise diagnostic pathway can enhance diagnostic accuracy and treatment effectiveness. A standardized initial assessment, risk stratification, and appropriate test identification facilitate determining the underlying cause in the majority of cases. New technologies, including artificial intelligence and smart devices, may have the potential to reshape syncope management into a proactive, personalized, and data-centric model, ultimately enhancing patient outcomes and quality of life. This review addresses key aspects of syncope management, including pathogenesis, current diagnostic testing options, treatments, and considerations in the geriatric population.
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Affiliation(s)
- Anna Maria Martone
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Iris Parrini
- Department of Cardiology, Mauriziano Hospital, Largo Filippo Turati, 62, 10128 Turin, Italy
| | - Francesca Ciciarello
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
| | - Vincenzo Galluzzo
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
| | - Stefano Cacciatore
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Claudia Massaro
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Rossella Giordano
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Tommaso Giani
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
| | - Giovanni Landi
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
| | | | - Furio Colivicchi
- Division of Cardiology, San Filippo Neri Hospital-ASL Roma 1, Via Giovanni Martinotti, 20, 00135 Rome, Italy;
| | - Domenico Gabrielli
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, S. Camillo-Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152 Rome, Italy;
| | - Fabrizio Oliva
- “A. De Gasperis” Cardiovascular Department, Division of Cardiology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore, 3, 20162 Milan, Italy;
| | - Giuseppe Zuccalà
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy; (A.M.M.); (F.C.); (V.G.); (G.L.); (G.Z.)
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy; (C.M.); (R.G.); (T.G.)
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Mu H, Liu J, Huang C, Tang H, Li S, Dong C, Yang T, Liu L, Xu B. Application of five risk stratification tools for syncope in older adults. J Int Med Res 2024; 52:3000605231220894. [PMID: 38190847 PMCID: PMC10775749 DOI: 10.1177/03000605231220894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/24/2023] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVE Treatment of syncope in older adults places a burden on healthcare systems. We used five risk stratification tools to predict short-term adverse outcomes in older patients with syncope. METHODS This was a retrospective analysis of patients with syncope (age ≥60 years) in the emergency department of an urban academic hospital. The data were evaluated using the Risk Stratification of Syncope in the Emergency Department (ROSE), San Francisco Syncope Rule (SFSR), FAINT, Canadian Syncope Risk Score (CSRS), and Boston Syncope Criteria (BSC) tools. Sensitivity, specificity, accuracy, positive and negative predictive value (NPV), and positive and negative likelihood ratios of each tool were calculated and compared for adverse events within 1 month. RESULTS In total, 221 patients (average age 75.6 years) were analyzed. Fifty-nine patients (26.7%) had experienced an adverse event within 1 month. For the ROSE, SFSR, FAINT, CSRS and BSC tools, sensitivities were 81.3%, 76.3%, 93.2%, 71.2%, and 94.9%, specificities were 88.3%, 87.7%, 56.8%, 71.6%, and 67.3%, and NPVs were 92.9%, 91.0%, 95.8%, 87.2%, and 97.3%, respectively. CONCLUSION The five assessed tools could be useful for physicians in screening older patients with syncope for the risk of short-term adverse events, according to the patient's actual situation.
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Affiliation(s)
- Hong Mu
- Department of Emergency, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiexin Liu
- Department of Neurocardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Cheng Huang
- Pingmo Health Center, Daozhen County, Zunyi, Guizhou, China
| | - Hefei Tang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Sisi Li
- The Fifth Medical College, Capital Medical University, Beijing, China
| | - Chang Dong
- The Fifth Medical College, Capital Medical University, Beijing, China
| | - Tiecheng Yang
- Department of Emergency, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Limin Liu
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Bin Xu
- Department of Emergency, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Ince C, Gulen M, Acehan S, Sevdimbas S, Balcik M, Yuksek A, Satar S. Comparison of syncope risk scores in predicting the prognosis of patients presenting to the emergency department with syncope. Ir J Med Sci 2023; 192:2727-2734. [PMID: 37171572 DOI: 10.1007/s11845-023-03395-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/27/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Various scores have been derived for the assessment of syncope patients in the emergency department (ED). AIM We aimed to compare the effectiveness of Canadian Syncope Risk Scores (CSRS), San Francisco Syncope Rules (SFSR), and Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk scores in predicting the risk of major adverse cardiac events (MACE) and mortality among syncope patients within 30 days of the initial ED visit. METHODS We performed a prospective, observational case series study of adults (≥ 18 years) with unexplained syncope/near-syncope who presented to ED. Demographic characteristics of the patients and clinical and laboratory data were recorded in the standard data collection form of the study. Our primary outcome was a 30-day mortality. RESULTS A total of 421 patients (mean age 50.9 ± 20.8, 51.5% male) were enrolled. The rate of MACE development in the 30-day follow-up of the patients was 12.8% (n = 54). While 20.2% (n = 85) of the patients were hospitalized, two of the patients died in the emergency room and the 30-day mortality was 5.5% (n = 23). CSRS was found to have the highest predictive power of mortality (AUC: 0.869, 95% CI 0.799-0.939, p < 0.001). If the cut-off value of CSRS was 0.5, the sensitivity was found to be 82.6% and the specificity was 81.9%. Also CSRS (OR: 1.402, 95% CI: 1.053-1.867, p = 0.021) was found to be an independent predictor of the 30-day mortality. CONCLUSION The CSRS may be used as a safety risk score for a 30-day risk of MACE and mortality after discharge from the emergency department.
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Affiliation(s)
- Cagdas Ince
- Clinic of Emergency Medicine, Health Sciences University Adana City Training and Research Hospital, Adana, Yuregir, 01370, Turkey
| | - Muge Gulen
- Clinic of Emergency Medicine, Health Sciences University Adana City Training and Research Hospital, Adana, Yuregir, 01370, Turkey.
| | - Selen Acehan
- Clinic of Emergency Medicine, Health Sciences University Adana City Training and Research Hospital, Adana, Yuregir, 01370, Turkey
| | - Sarper Sevdimbas
- Clinic of Emergency Medicine, Health Sciences University Adana City Training and Research Hospital, Adana, Yuregir, 01370, Turkey
| | - Muhammet Balcik
- Department of Emergency Medicine, Kahramanmaras Necip Fazıl City Hospital, Kahramanmaras, Turkey
| | - Ali Yuksek
- Department of Emergency Medicine, Hatay City Training and Research Hospital, Hatay, Turkey
| | - Salim Satar
- Clinic of Emergency Medicine, Health Sciences University Adana City Training and Research Hospital, Adana, Yuregir, 01370, Turkey
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Del Pozo Vegas C, Zalama-Sánchez D, Sanz-Garcia A, López-Izquierdo R, Sáez-Belloso S, Mazas Perez Oleaga C, Domínguez Azpíroz I, Elío Pascual I, Martín-Rodríguez F. Prehospital acute life-threatening cardiovascular disease in elderly: an observational, prospective, multicentre, ambulance-based cohort study. BMJ Open 2023; 13:e078815. [PMID: 37996229 PMCID: PMC10668192 DOI: 10.1136/bmjopen-2023-078815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/09/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVE The aim was to explore the association of demographic and prehospital parameters with short-term and long-term mortality in acute life-threatening cardiovascular disease by using a hazard model, focusing on elderly individuals, by comparing patients under 75 years versus patients over 75 years of age. DESIGN Prospective, multicentre, observational study. SETTING Emergency medical services (EMS) delivery study gathering data from two back-to-back studies between 1 October 2019 and 30 November 2021. Six advanced life support (ALS), 43 basic life support and five hospitals in Spain were considered. PARTICIPANTS Adult patients suffering from acute life-threatening cardiovascular disease attended by the EMS. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was in-hospital mortality from any cause within the first to the 365 days following EMS attendance. The main measures included prehospital demographics, biochemical variables, prehospital ALS techniques used and syndromic suspected conditions. RESULTS A total of 1744 patients fulfilled the inclusion criteria. The 365-day cumulative mortality in the elderly amounted to 26.1% (229 cases) versus 11.6% (11.6%) in patients under 75 years old. Elderly patients (≥75 years) presented a twofold risk of mortality compared with patients ≤74 years. Life-threatening interventions (mechanical ventilation, cardioversion and defibrillation) were also related to a twofold increased risk of mortality. Importantly, patients suffering from acute heart failure presented a more than twofold increased risk of mortality. CONCLUSIONS This study revealed the prehospital variables associated with the long-term mortality of patients suffering from acute cardiovascular disease. Our results provide important insights for the development of specific codes or scores for cardiovascular diseases to facilitate the risk of mortality characterisation.
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Affiliation(s)
- Carlos Del Pozo Vegas
- Emergency Department, Hospital Clinico Universitario de Valladolid, Valladolid, Castilla y León, Spain
- Universidad de Valladolid, Valladolid, Spain
| | - Daniel Zalama-Sánchez
- Emergency Department, Hospital Clinico Universitario de Valladolid, Valladolid, Castilla y León, Spain
| | - Ancor Sanz-Garcia
- University of Castilla-La Mancha-Center for University Studies Talavera de la Reina, Talavera de la Reina, Castilla-La Mancha, Spain
| | - Raúl López-Izquierdo
- Universidad de Valladolid, Valladolid, Spain
- Hosp Univ Rio Hortega, Valladolid, Spain
- CIBER of Respiratory Diseases, Instituto de Salud Carlos III, Madrid, Spain
| | - Silvia Sáez-Belloso
- Universidad de Valladolid, Valladolid, Spain
- Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain
| | - Cristina Mazas Perez Oleaga
- Universidad Europea del Atlántico, Santander, Spain
- Universidad Internacional Iberoamericana, Arecibo, Puerto Rico, USA
- Universidad de La Romana, La Romana, Dominican Republic
| | - Irma Domínguez Azpíroz
- Universidad Europea del Atlántico, Santander, Spain
- Universidad Internacional Iberoamericana, Campeche, Mexico
- Universidade Internacional do Cuanza, Cuito, Bié, Angola
| | - Iñaki Elío Pascual
- Universidad Europea del Atlántico, Santander, Spain
- Universidade Internacional do Cuanza, Cuito, Bié, Angola
- Fundación Universitaria Internacional de Colombia, Bogotá, Colombia
| | - Francisco Martín-Rodríguez
- Universidad de Valladolid, Valladolid, Spain
- Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain
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Baugh CW, Freund Y, Steg PG, Body R, Maron DJ, Yiadom MYAB. Strategies to mitigate emergency department crowding and its impact on cardiovascular patients. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:633-643. [PMID: 37163667 DOI: 10.1093/ehjacc/zuad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/12/2023]
Abstract
Emergency department (ED) crowding is a worsening global problem caused by hospital capacity and other health system challenges. While patients across a broad spectrum of illnesses may be affected by crowding in the ED, patients with cardiovascular emergencies-such as acute coronary syndrome, malignant arrhythmias, pulmonary embolism, acute aortic syndrome, and cardiac tamponade-are particularly vulnerable. Because of crowding, patients with dangerous and time-sensitive conditions may either avoid the ED due to anticipation of extended waits, leave before their treatment is completed, or experience delays in receiving care. In this educational paper, we present the underlying causes of crowding and its impact on common cardiovascular emergencies using the input-throughput-output process framework for patient flow. In addition, we review current solutions and potential innovations to mitigate the negative effect of ED crowding on patient outcomes.
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Affiliation(s)
- Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Neville House 2nd Floor, Boston, MA 02115, USA
| | - Yonathan Freund
- Emergency Department Hospital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Philippe Gabriel Steg
- Department of Cardiology, Université Paris-Cité, Institut Universitaire de France, FACT, French Alliance for Cardiovascular Trials, INSERM-1148, and Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Richard Body
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
- Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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Uit Het Broek LG, Ort BBA, Vermeulen H, Pelgrim T, Vloet LCM, Berben SAA. Risk stratification tools for patients with syncope in emergency medical services and emergency departments: a scoping review. Scand J Trauma Resusc Emerg Med 2023; 31:48. [PMID: 37723535 PMCID: PMC10508018 DOI: 10.1186/s13049-023-01102-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 07/16/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Patients with a syncope constitute a challenge for risk stratification in (prehospital) emergency care. Professionals in EMS and ED need to differentiate the high-risk from the low-risk syncope patient, with limited time and resources. Clinical decision rules (CDRs) are designed to support professionals in risk stratification and clinical decision-making. Current CDRs seem unable to meet the standards to be used in the chain of emergency care. However, the need for a structured approach for syncope patients remains. We aimed to generate a broad overview of the available risk stratification tools and identify key elements, scoring systems and measurement properties of these tools. METHODS We performed a scoping review with a literature search in MEDLINE, CINAHL, Pubmed, Embase, Cochrane and Web of Science from January 2010 to May 2022. Study selection was done by two researchers independently and was supervised by a third researcher. Data extraction was performed through a data extraction form, and data were summarised through descriptive synthesis. A quality assessment of included studies was performed using a generic quality assessment tool for quantitative research and the AMSTAR-2 for systematic reviews. RESULTS The literature search identified 5385 unique studies; 38 were included in the review. We discovered 19 risk stratification tools, one of which was established in EMS patient care. One-third of risk stratification tools have been validated. Two main approaches for the application of the tools were identified. Elements of the tools were categorised in history taking, physical examination, electrocardiogram, additional examinations and other variables. Evaluation of measurement properties showed that negative and positive predictive value was used in half of the studies to assess the accuracy of tools. CONCLUSION A total of 19 risk stratification tools for syncope patients were identified. They were primarily established in ED patient care; most are not validated properly. Key elements in the risk stratification related to a potential cardiac problem as cause for the syncope. These insights provide directions for the key elements of a risk stratification tool and for a more advanced process to validate risk stratification tools.
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Affiliation(s)
- Lucia G Uit Het Broek
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands.
| | - B Bastiaan A Ort
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Hester Vermeulen
- Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Thomas Pelgrim
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Lilian C M Vloet
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Sivera A A Berben
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
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11
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Kiradoh SA, Craven TE, Rangel MO, Nosow LM, Zarrinkhoo E, Menon S, Chevli PA, Islam TM, Thazhatuveetil-Kunhahamed LA. Predicting short-term adverse outcomes in the geriatric population presenting with syncope: a comparison of existing syncope rules and beyond. J Geriatr Cardiol 2023; 20:11-22. [PMID: 36875169 PMCID: PMC9975484 DOI: 10.26599/1671-5411.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
OBJECTIVES Syncope at age 65+ is associated with increased mortality, irrespective of cause. Syncope rules were designed to aid in risk-stratification but were only validated in the general adult population. Our objective was to determine if they can be applied to a geriatric population in predicting short-term adverse outcomes. METHODS In this single-center retrospective study, we evaluated 350 patients aged 65+ presenting with syncope. Exclusion criteria included confirmed non-syncope, active medical condition, drug or alcohol-related syncope. Patients were stratified into high or low risk based on Canadian Syncope Risk Score (CSRS), Evaluation of Guidelines in Syncope Study (EGSYS), San Francisco Syncope Rule (SFSR), and Risk Stratification of Syncope in the Emergency Department (ROSE). Composite adverse outcomes at 48-hour and 30-day included all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE), return emergency department visit, hospitalization, or medical intervention. We assessed each score's ability to predict the outcomes using logistic-regression and compared performances using receiver-operator curves. Multivariate analyses were performed to study the associations between recorded parameters and outcomes. RESULTS CSRS outperformed with AUC of 0.732 (95% CI: 0.653-0.812) and 0.749 (95% CI: 0.688-0.809) for 48-h and 30-day outcomes, respectively. Sensitivities for CSRS, EGSYS, SFSR, and ROSE for 48-hour outcomes were 48%, 65%, 42% and 19%; and for 30-day outcomes were 72%, 65%, 30% and 55%, respectively. Atrial fibrillation/flutter on EKG, congestive heart failure, antiarrhythmics, systolic blood-pressure < 90 at triage, and associated chest pain highly correlated with 48-h outcomes. An EKG abnormality, heart disease history, severe pulmonary hypertension, BNP > 300, vasovagal predisposition, and antidepressants highly correlated with 30-day outcomes. CONCLUSIONS Performance and accuracy of four prominent syncope rules were suboptimal in identifying high-risk geriatric patients with short-term adverse outcomes. We identified some significant clinical and laboratory information that may play a role in predicting short-term adverse events in a geriatric cohort.
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Affiliation(s)
- Suud A Kiradoh
- Department of Internal Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Timothy E Craven
- Biostatistics, Epidemiology, Research, and Design (BERD), Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Maria O Rangel
- Department of Cardiology, Atrium Health Wake Forest Baptist Medical Center, USA
| | - Lillian M Nosow
- Department of Internal Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Erfan Zarrinkhoo
- Department of Internal Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Suma Menon
- Department of Internal Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Parag A Chevli
- Department of Internal Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Tareq M Islam
- Department of Internal Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
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12
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Quinn J, Kim D, Rice BT, Hao WD. Natural language processing to classify electrocardiograms in patients with syncope: A preliminary study. Health Sci Rep 2022; 5:e904. [PMID: 36324425 PMCID: PMC9621468 DOI: 10.1002/hsr2.904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/16/2022] [Accepted: 10/10/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- James Quinn
- Department of Emergency MedicineStanford UniversityCaliforniaStanfordUSA
| | - David Kim
- Department of Emergency MedicineStanford UniversityCaliforniaStanfordUSA
| | - Brian Travis Rice
- Department of Emergency MedicineStanford UniversityCaliforniaStanfordUSA
| | - Wei David Hao
- Department of Emergency MedicineStanford UniversityCaliforniaStanfordUSA
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13
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Lo AX, Rundle AG. Everyone eventually goes to ground: Distinguishing true syncope from mimics for emergency department studies on syncope in older persons. J Am Coll Emerg Physicians Open 2022; 3:e12841. [PMID: 36311341 PMCID: PMC9597094 DOI: 10.1002/emp2.12841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Alexander X. Lo
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA,Center for Health Services & Outcomes ResearchNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Andrew G. Rundle
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
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14
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Voigt RD, Alsayed M, Bellolio F, Campbell RL, Mullan A, Colleti JE, Oliveira J. e Silva L. Prognostic accuracy of syncope clinical prediction rules in older adults in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12820. [PMID: 36311342 PMCID: PMC9597095 DOI: 10.1002/emp2.12820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/03/2022] [Accepted: 07/14/2022] [Indexed: 11/06/2022] Open
Abstract
Study objective The objective of this study is to evaluate the prognostic accuracy of existing rules (San Francisco Syncope Rule [SFSR], Canadian Syncope Risk Score [CSRS], and FAINT score) in older adults. Methods This is a cohort study of adults aged ≥60 years presenting to an academic emergency department (ED) with syncope or near syncope. We used original criteria for all rules except for the FAINT score, in which N‐terminal pro–brain natriuretic peptide was largely missing from the extracted data. Patients were deemed positive for each rule if classified as non‐low risk. The primary outcome was the presence of 30‐day serious outcome, as defined by syncope research guidelines. Sensitivity and negative likelihood ratio (NLR) were calculated with 95% confidence intervals (CIs). Results A total of 404 ED visits (mean age of patients, 75.5 years) were included. Of these, 44 (10.9%) had a 30‐day serious outcome, and 24 (5.9%) had incomplete 30‐day follow‐up. SFSR was positive for 280 of 380 visits with complete follow‐up. Its sensitivity and NLR for predicting 30‐day serious outcomes were 86.4% (95% CI, 72.0%–94.3%) and 0.53 (95% CI, 0.25–1.15), respectively. The CSRS was positive for 299 of 380 visits (sensitivity was 88.6% [95% CI, 76.4%–95.7%], and NLR was 0.50 [95% CI, 0.22–1.17]). The modified FAI(N)T score was positive for 318 of 380 visits (sensitivity was 90.9% [95% CI, 77.4%–97.0%], and NLR was 0.53 [95% CI, 0.20–1.38]). Conclusion Existing rules are suboptimal to predict 30‐day serious outcomes in older adults presenting with syncope or near syncope to the ED.
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Affiliation(s)
- Richard D. Voigt
- Department of Emergency MedicineMayo ClinicRochesterMinnesotaUSA
| | - Momen Alsayed
- Department of Emergency MedicineMayo ClinicRochesterMinnesotaUSA
| | - Fernanda Bellolio
- Department of Emergency MedicineMayo ClinicRochesterMinnesotaUSA,Department of Health Sciences ResearchMayo ClinicRochesterMinnesotaUSA
| | | | - Aidan Mullan
- Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA
| | - James E. Colleti
- Department of Emergency MedicineMayo ClinicRochesterMinnesotaUSA
| | - Lucas Oliveira J. e Silva
- Department of Emergency MedicineMayo ClinicRochesterMinnesotaUSA,Department of Emergency MedicineHospital de Clínicas de Porto AlegrePorto AlegreRSBrazil
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15
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Clemmensen SLK, Kragholm K, Tayal B, Torp-Pedersen C, Kold S, Søgaard P, Riahi S. Risk of pacemaker implantation after femur fracture in patients with and without a history syncope: a Danish nationwide registry-based follow-up study. J Geriatr Cardiol 2022; 19:712-718. [PMID: 36284681 PMCID: PMC9548056 DOI: 10.11909/j.issn.1671-5411.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND It has previously been described that fall-associated injuries including fractures are commonly observed among patients with bradyarrhythmia. However, knowledge on the risk of pacemaker implantation after admission due to femur fracture from large population-based epidemiologic data is lacking. Therefore, we investigated the risk of pacemaker implantation following femur fracture in patients with and without a history of previous syncope. METHODS All patients with femur fracture between 2005-2017 were identified using the Danish Nationwide Patient Registry. Among these, patients already having a pacemaker were excluded. Primary outcome was one-year risk of pacemaker implantation and secondary outcome was one-year all-cause mortality. Multivariable logistic regression was used to obtain absolute and relative risks of the study endpoint in relation to patients with versus without history of syncope and standardized to the age, sex, selected comorbidity and pharmacotherapy distribution of all patients. RESULTS Of 93,093 patients with femur fracture, 5508 (5.9%) had a history of syncope within five years. Patients with prior syncope were slightly older (84 vs. 83 years), more often male (33.6% vs. 29.4%), and had more often comorbidities relative to those without history of syncope. All-cause mortality was significantly higher among those with previous history of syncope compared to those without previous syncope (29.9% vs. 28.6%, P = 0.021). The relative mortality risk was 1.05 (95% CI: 1.01-1.09, P = 0.021). A total of 695 (0.8%) patients underwent pacemaker implantation within 5 years following femur fracture, and a significantly higher proportion of patients with syncope had a pacemaker implanted within one year (1.6% vs. 0.7%, P < 0.001; relative risk, 2.01 [95% CI: 1.55-2.46]). CONCLUSIONS In patients with femur fracture, a history of syncope was significantly associated with a higher one-year risk of pacemaker implantation.
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Affiliation(s)
| | - Kristian Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Bhupendar Tayal
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Kold
- Department of Orthopedics, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
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16
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Probst MA, Janke AT, Haimovich AD, Venkatesh AK, Lin MP, Kocher KE, Nemnom MJ, Thiruganasambandamoorthy V. Development of a Novel Emergency Department Quality Measure to Reduce Very Low-Risk Syncope Hospitalizations. Ann Emerg Med 2022; 79:509-517. [PMID: 35487840 PMCID: PMC9117517 DOI: 10.1016/j.annemergmed.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE Emergency department (ED) evaluations for syncope are common, representing 1.3 million annual US visits and $2 billion in related hospitalizations. Despite evidence supporting risk stratification and outpatient management, variation in syncope hospitalization rates persist. We sought to develop a new quality measure for very low-risk adult ED patients with syncope that could be applied to administrative data. METHODS We developed this quality measure in 2 phases. First, we used an existing prospective, observational ED patient data set to identify a very low-risk cohort with unexplained syncope using 2 variables: age less than 50 years and no history of heart disease. We then applied this to the 2019 Nationwide Emergency Department Sample (NEDS) to assess its potential effect, assessing for hospital-level factors associated with hospitalization variation. RESULTS Of the 8,647 adult patients in the prospective cohort, 3,292 (38%) patients fulfilled these 2 criteria: age less than 50 years and no history of heart disease. Of these, 15 (0.46%) suffered serious adverse events within 30 days. In the NEDS, there were an estimated 566,031 patients meeting these 2 criteria, of whom 15,507 (2.7%; 95% confidence interval [CI] 2.48% to 3.00%) were hospitalized. We found substantial variation in the hospitalization rates for this very low-risk cohort, with a median rate of 1.7% (range 0% to 100%; interquartile range 0% to 3.9%). Factors associated with increased hospitalization rates included a yearly ED volume of more than 80,000 (odds ratio [OR] 3.14; 95% CI 2.02 to 4.89) and metropolitan teaching status (OR 1.5; 95% CI 1.24 to 1.81). CONCLUSION In summary, our novel syncope quality measure can assess variation in low-value hospitalizations for unexplained syncope. The application of this measure could improve the value of syncope care.
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Affiliation(s)
- Marc A Probst
- Department of Emergency Medicine, Columbia University Medical Center, New York, NY.
| | - Alexander T Janke
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Adrian D Haimovich
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Michelle P Lin
- Department of Emergency Medicine and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Keith E Kocher
- Department of Emergency Medicine and Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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17
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Zimmermann T, du Fay de Lavallaz J, Nestelberger T, Gualandro DM, Lopez-Ayala P, Badertscher P, Widmer V, Shrestha S, Strebel I, Glarner N, Diebold M, Miró Ò, Christ M, Cullen L, Than M, Martin-Sanchez FJ, Di Somma S, Peacock WF, Keller DI, Bilici M, Costabel JP, Kühne M, Breidthardt T, Thiruganasambandamoorthy V, Mueller C, Belkin M, Leu K, Lohrmann J, Boeddinghaus J, Twerenbold R, Koechlin L, Walter JE, Amrein M, Wussler D, Freese M, Puelacher C, Kawecki D, Morawiec B, Salgado E, Martinez-Nadal G, Inostroza CIF, Mandrión JB, Poepping I, Rentsch K, von Eckardstein A, Buser A, Greenslade J, Reichlin T, Bürgler F. International Validation of the Canadian Syncope Risk Score : A Cohort Study. Ann Intern Med 2022; 175:783-794. [PMID: 35467933 DOI: 10.7326/m21-2313] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The Canadian Syncope Risk Score (CSRS) was developed to predict 30-day serious outcomes not evident during emergency department (ED) evaluation. OBJECTIVE To externally validate the CSRS and compare it with another validated score, the Osservatorio Epidemiologico della Sincope nel Lazio (OESIL) score. DESIGN Prospective cohort study. SETTING Large, international, multicenter study recruiting patients in EDs in 8 countries on 3 continents. PARTICIPANTS Patients with syncope aged 40 years or older presenting to the ED within 12 hours of syncope. MEASUREMENTS Composite outcome of serious clinical plus procedural events (primary outcome) and the primary composite outcome excluding procedural interventions (secondary outcome). RESULTS Among 2283 patients with a mean age of 68 years, the primary composite outcome occurred in 7.2%, and the composite outcome excluding procedural interventions occurred in 3.1% at 30 days. Prognostic performance of the CSRS was good for both 30-day composite outcomes and better compared with the OESIL score (area under the receiver-operating characteristic curve [AUC], 0.85 [95% CI, 0.83 to 0.88] vs. 0.74 [CI, 0.71 to 0.78] and 0.80 [CI, 0.75 to 0.84] vs. 0.69 [CI, 0.64 to 0.75], respectively). Safety of triage, as measured by the frequency of the primary composite outcome in the low-risk group, was higher using the CSRS (19 of 1388 [0.6%]) versus the OESIL score (17 of 1104 [1.5%]). A simplified model including only the clinician classification of syncope (cardiac syncope, vasovagal syncope, or other) variable at ED discharge-a component of the CSRS-achieved similar discrimination as the CSRS (AUC, 0.83 [CI, 0.80 to 0.87] for the primary composite outcome). LIMITATION Unable to disentangle the influence of other CSRS components on clinician classification of syncope at ED discharge. CONCLUSION This international external validation of the CSRS showed good performance in identifying patients at low risk for serious outcomes outside of Canada and superior performance compared with the OESIL score. However, clinician classification of syncope at ED discharge seems to explain much of the performance of the CSRS in this study. The clinical utility of the CSRS remains uncertain. PRIMARY FUNDING SOURCE Swiss National Science Foundation & Swiss Heart Foundation.
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Affiliation(s)
- Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, and Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (T.Z.)
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, GREAT Network, Rome, Italy, and Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (T.N.)
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, GREAT Network, Rome, Italy, and Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil (D.M.G.)
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Velina Widmer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland (V.W., N.G.)
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland (V.W., N.G.)
| | - Matthias Diebold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Òscar Miró
- GREAT Network, Rome, Italy, and Hospital Clinic, Barcelona, Catalonia, Spain (Ò.M.)
| | - Michael Christ
- GREAT Network, Rome, Italy, and Kantonsspital Luzern, Luzern, Switzerland (M.C.)
| | - Louise Cullen
- GREAT Network, Rome, Italy, and Royal Brisbane & Women's Hospital, Herston, Australia (L.C.)
| | - Martin Than
- GREAT Network, Rome, Italy, and Christchurch Hospital, Christchurch, New Zealand (M.T.)
| | - F Javier Martin-Sanchez
- GREAT Network, Rome, Italy, and Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain (F.J.M.)
| | - Salvatore Di Somma
- GREAT Network, Rome, Italy, and Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Italy (S.D.S.)
| | - W Frank Peacock
- GREAT Network, Rome, Italy, and Baylor College of Medicine, Department of Emergency Medicine, Houston, Texas (W.F.P.)
| | - Dagmar I Keller
- Emergency Department, University Hospital Zürich, Zürich, Switzerland (D.I.K.)
| | - Murat Bilici
- Department of Orthopedics and Traumatology, University Hospital Basel, University of Basel, Basel, Switzerland (M.B.)
| | | | - Michael Kühne
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Tobias Breidthardt
- Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, and Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (T.B.)
| | | | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
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18
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du Fay de Lavallaz J, Zimmermann T, Badertscher P, Lopez-Ayala P, Nestelberger T, Miró Ò, Salgado E, Zaytseva X, Gafner MS, Christ M, Cullen L, Than M, Martin-Sanchez FJ, Di Somma S, Peacock WF, Keller DI, Costabel JP, Sigal A, Puelacher C, Wussler D, Koechlin L, Strebel I, Schuler S, Manka R, Bilici M, Lohrmann J, Kühne M, Breidthardt T, Clark CL, Probst M, Gibson TA, Weiss RE, Sun BC, Mueller C. Performance of the American Heart Association/American College of Cardiology/Heart Rhythm Society versus European Society of Cardiology guideline criteria for hospital admission of patients with syncope. Heart Rhythm 2022; 19:1712-1722. [PMID: 35644354 DOI: 10.1016/j.hrthm.2022.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/28/2022] [Accepted: 05/23/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Current American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) and European Society of Cardiology (ESC) guidelines recommend different strategies to avoid low-yield admissions in patients with syncope. OBJECTIVE The purpose of this study was to directly compare the safety and efficacy of applying admission criteria of both guidelines to patients presenting with syncope to the emergency department in 2 multicenter studies. METHODS The international BASEL IX (BAsel Syncope EvaLuation) study (median age 71 years) and the U.S. SRS (Improving Syncope Risk Stratification in Older Adults) study (median age 72 years) were investigated. Primary endpoints were sensitivity/specificity for the adjudicated diagnosis of cardiac syncope (BASEL IX only) and 30-day major adverse cardiovascular events (30d-MACE). RESULTS Among 2560 patients in the BASEL IX and 2085 in SRS studies, ACC/AHA/HRS and ESC criteria recommended admission for a comparable number of patients in BASEL IX (27% vs 28%), but ACC/AHA/HRS criteria less often in SRS (19% vs 32%; P <.01). Recommendations were discordant in ∼25% of patients. In BASEL IX, sensitivity for cardiac syncope and 30d-MACE among patients without admission criteria was comparable for ACC/AHA/HRS and ESC criteria (64% vs 65%, P = .86; and 67% vs 71%, P = .15, respectively). In SRS, sensitivity for 30d-MACE was lower with ACC/AHA/HRS (54%) vs ESC criteria (88%; P <.001). Similarly, specificity for cardiac syncope and 30d-MACE in BASEL IX was comparable for both guidelines, but in SRS the ACC/AHA/HRS guidelines showed a higher specificity for 30d-MACE than the ESC guidelines. CONCLUSION ACC/AHA/HRS and ESC guidelines showed disagreement regarding admission for 1 in 4 patients and had only modest sensitivity, all indicating possible opportunities for improvements.
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Affiliation(s)
- Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network.
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Òscar Miró
- GREAT Network; Hospital Clinic, Barcelona, Catalonia, Spain
| | - Emilio Salgado
- GREAT Network; Hospital Clinic, Barcelona, Catalonia, Spain
| | - Xenia Zaytseva
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; University Hospital Zürich, Zürich, Switzerland
| | - Michele Sara Gafner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Michael Christ
- Department of Emergency Medicine, Kantonsspital Luzern, Lucerne, Switzerland
| | - Louise Cullen
- GREAT Network; Royal Brisbane & Women's Hospital, Herston, Australia
| | - Martin Than
- GREAT Network; Christchurch Hospital, Christchurch, New Zealand
| | | | - Salvatore Di Somma
- GREAT Network; Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Rome, Italy
| | - W Frank Peacock
- GREAT Network; Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | | | | | - Alan Sigal
- Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Sereina Schuler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; University Hospital Zürich, Zürich, Switzerland
| | | | - Murat Bilici
- Department of Orthopedics and Traumatology, Basel University Hospital, Basel, Switzerland
| | - Jens Lohrmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael Kühne
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tobias Breidthardt
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Carol L Clark
- Beaumont Health System-Royal Oak, Royal Oak, Michigan
| | - Marc Probst
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York
| | - Thomas A Gibson
- Department of Biostatistics, University of California Fielding School of Public Health, Los Angeles, California
| | - Robert E Weiss
- Department of Biostatistics, University of California Fielding School of Public Health, Los Angeles, California
| | - Benjamin C Sun
- Department of Emergency Medicine, Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
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Sutton R, Ricci F, Fedorowski A. Risk stratification of syncope: Current syncope guidelines and beyond. Auton Neurosci 2022; 238:102929. [PMID: 34968831 DOI: 10.1016/j.autneu.2021.102929] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/27/2021] [Accepted: 12/08/2021] [Indexed: 11/28/2022]
Abstract
Syncope is an alarming event carrying the possibility of serious outcomes, including sudden cardiac death (SCD). Therefore, immediate risk stratification should be applied whenever syncope occurs, especially in the Emergency Department, where most dramatic presentations occur. It has long been known that short- and long-term syncope prognosis is affected not only by its mechanism but also by presence of concomitant conditions, especially cardiovascular disease. Over the last two decades, several syncope prediction tools have been developed to refine patient stratification and triage patients who need expert in-hospital care from those who may receive nonurgent expert care in the community. However, despite promising results, prognostic tools for syncope remain challenging and often poorly effective. Current European Society of Cardiology syncope guidelines recommend an initial syncope workup based on detailed patient's history, physical examination supine and standing blood pressure, resting ECG, and laboratory tests, including cardiac biomarkers, where appropriate. Subsequent risk stratification based on screening of features aims to identify three groups: high-, intermediate- and low-risk. The first should immediately be hospitalized and appropriately investigated; intermediate group, with recurrent or medium-risk events, requires systematic evaluation by syncope experts; low-risk group, sporadic reflex syncope, merits education about its benign nature, and discharge. Thus, initial syncope risk stratification is crucial as it determines how and by whom syncope patients are managed. This review summarizes the crucial elements of syncope risk stratification, pros and cons of proposed risk evaluation scores, major challenges in initial syncope management, and how risk stratification impacts management of high-risk/recurrent syncope.
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Affiliation(s)
- Richard Sutton
- National Heart & Lung Institute, Imperial College, Dept. of Cardiology, Hammersmith Hospital, Du Cane Road, London W12 0HS, United Kingdom
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, Via Luigi Polacchi, 11, 66100 Chieti, Italy; Casa di Cura Villa Serena, Città Sant'Angelo, Italy
| | - Artur Fedorowski
- Dept. of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Stockholm, Sweden.
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Almulhim KN. The Characteristics of Syncope-Related Emergency Department Visits: Resource Utilization and Admission Rate Patterns in Emergency Departments. Cureus 2022; 14:e22039. [PMID: 35340474 PMCID: PMC8913182 DOI: 10.7759/cureus.22039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 11/05/2022] Open
Abstract
Background and objective Decision-making about syncope patients presenting to the emergency department (ED) is challenging since physicians must balance the minimal risks of life-threatening conditions with the unessential use of expensive imaging or unnecessary hospitalizations. This study aimed to determine the characteristics of ED visits, resource utilization, and admission rate patterns related to syncope in the United States (US) during the period 2005-2015. Methods Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) on ED visits during the 11-year period from 2005 to 2015 were retrieved. ED visits for syncope were identified and compared against non-syncope ED visits. The demographic and clinical characteristics of patients, as well data on resource allocation and admission trends were captured and described for the syncope and the non-syncope groups. Results Syncope accounted for 1.11% of the total ED visits during the study period from 2005 to 2015. The incidence of syncope-related ED visits was higher among elderly females, whites, and non-Hispanics. The trend of admission rates showed a decline from about 30% in 2005-2010 to less than 20% in 2014 and 2015. Advanced imaging (CT or MRI) was ordered for 34% of syncope patients. Conclusion The percentage of syncope-related ED visits remained stable during the study period, but the admission rates declined while the use of advanced imaging in syncope-related ED visits remained substantially high despite the advances in research and availability of clinical guidelines. Future research is needed to rationalize healthcare utilization in syncope-related ED visits and precisely identify the high-risk population.
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Liang Y, Li X, Tse G, King E, Roever L, Li G, Liu T. Syncope Prediction Scores in the Emergency Department. Curr Cardiol Rev 2022; 18:1-7. [PMID: 35319380 PMCID: PMC9896417 DOI: 10.2174/1573403x18666220321104129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/03/2021] [Accepted: 01/10/2022] [Indexed: 11/22/2022] Open
Abstract
Syncope is a common clinical presentation defined as a transient loss of consciousness (TLOC) due to cerebral hypoperfusion, characterized by a rapid onset, short duration, and spontaneous complete recovery. Different clinical decision rules (CDRs) and risk stratification scores have been developed to predict short- and long-term risks for adverse outcomes after syncope. The central theme of these prediction systems is consistent with the ESC syncope guidelines. Initial assessment according to the ESC guideline is essential until an optimal and well-validated risk score is available. The focus should be accurate risk stratification to allow prevention of adverse outcomes and optimize the use of limited healthcare resources. In this review article, we summarize and critically appraise the evidence regarding the CDRs for patients presenting with syncope.
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Affiliation(s)
- Yan Liang
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Pingjiang Road, Hexi District, Tianjin 300211, People’s Republic of China
| | - Xiulian Li
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Pingjiang Road, Hexi District, Tianjin 300211, People’s Republic of China
| | - Gary Tse
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Pingjiang Road, Hexi District, Tianjin 300211, People’s Republic of China
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, Hong Kong, China
| | - Emma King
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Pingjiang Road, Hexi District, Tianjin 300211, People’s Republic of China
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, Hong Kong, China
| | | | - Guangping Li
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Pingjiang Road, Hexi District, Tianjin 300211, People’s Republic of China
| | - Tong Liu
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Pingjiang Road, Hexi District, Tianjin 300211, People’s Republic of China
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Safari S, Khasraghi ZS, Chegeni MA, Ghabousian A, Amini A. The ability of Canadian Syncope risk score in differentiating cardiogenic and non-cardiogenic syncope; a cross-sectional study. Am J Emerg Med 2021; 50:675-678. [PMID: 34879485 DOI: 10.1016/j.ajem.2021.07.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/06/2021] [Accepted: 07/09/2021] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Determining the underlying etiology of syncope provides valuable prognostic information and expedites the implementation of a therapeutic strategy. This study aimed to evaluate the ability of Canadian Syncope Risk Score (CSRS) in differentiating cardiogenic and non-cardiac syncope. METHODS The present diagnostic accuracy study was conducted on adult patients with syncope, who presented to the emergency departments of Shohadaye Tajrish and Imam Hossein Hospitals in Tehran from March 2018 to March 2019. The data required for determining CSRS were collected during the initial assessment and the underlying etiology was confirmed through further diagnostic follow-up under the supervision of a cardiologist or neurologist. Finally, the screening performance characteristics of the score were calculated. RESULTS 300 patients with the mean age of 56.38 ± 19.10 years were studied. The source of syncope was cardiac in 133 (44.3%) and non-cardiac in 137 (55.7%) patients. The area under the ROC curve of CSRS in differentiating cardiac syncope was 0.77 (95% CI: 0.715-0.824). At a cutoff point of -1.5, the sensitivity and specificity of the score were calculated to be 73.68% (95% CI: 65.21-80.75%) and 73.05% (95%CI: 75.54-79.47%), respectively. CONCLUSION The present study reveals that CSRS has fair accuracy in differentiating the source of syncope and has no superiority over a clinical examination. Therefore, we do not recommend relying on the CSRS to differentiate between cardiac and non-cardiac syncope alone.
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Affiliation(s)
- Saeed Safari
- Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Emergency Medicine Department, Shohadaye Tajrish Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Soltanzadeh Khasraghi
- Emergency Medicine Department, Shohadaye Tajrish Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Ahmadi Chegeni
- Emergency Medicine Department, Shohadaye Tajrish Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Ghabousian
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Afshin Amini
- Emergency Medicine Department, Imam Hossein Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Hatoum T, Sheldon RS. Syncope and the aging patient: Navigating the challenges. Auton Neurosci 2021; 237:102919. [PMID: 34856496 DOI: 10.1016/j.autneu.2021.102919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Abstract
Syncope in the elderly patient is a common presentation and the most common causes are usually non-cardiac. Older adults however are more challenging dilemmas as their presentation is complicated by co-morbidities, mainly cardiovascular and neurodegenerative disorders. Frailty and cognitive impairment add to the ambiguity of the presentation, and polypharmacy is often a major modifiable contributing factor. Vasovagal syncope is a common presentation throughout life even as we age. It has a favorable prognosis and conservative management usually suffices. Vasovagal syncope in this population may be misdiagnosed as accidental falls and is frequently associated with injury, as is carotid sinus syndrome. The initial approach to these patients entails a detailed history and physical examination including a comprehensive medication history, orthostatic vital signs, and a 12-lead electrocardiogram. Further cardiac and neuroimaging rarely helps, unless directed by specific clinical findings. Head-up tilt testing and carotid sinus massage retain their diagnostic accuracy and safety in the elderly, and implantable loop recorders provide important information in many elderly patients with unexplained falls and syncope. The starting point in management of this population with non-cardiac syncope is attempting to withdraw unnecessary vasoactive and psychotropic medications. Non-pharmacologic and pharmacologic therapy for syncope in the elderly has limited efficacy and safety concerns. In selected patients, pacemaker therapy might offer symptomatic relief despite lack of efficacy when vasodepression is prominent. An approach focused on primary care with targeted specialist referral seems a safe and effective strategy.
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Affiliation(s)
- Tarek Hatoum
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada.
| | - Robert S Sheldon
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
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Syncope Time Frames for Adverse Events after Emergency Department Presentation: An Individual Patient Data Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57111235. [PMID: 34833453 PMCID: PMC8623370 DOI: 10.3390/medicina57111235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/04/2021] [Accepted: 11/10/2021] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Knowledge of the incidence and time frames of the adverse events of patients presenting syncope at the ED is essential for developing effective management strategies. The aim of the present study was to perform a meta-analysis of the incidence and time frames of adverse events of syncope patients. Materials and Methods: We combined individual patients’ data from prospective observational studies including adult patients who presented syncope at the ED. We assessed the pooled rate of adverse events at 24 h, 72 h, 7–10 days, 1 month and 1 year after ED evaluation. Results: We included nine studies that enrolled 12,269 patients. The mean age varied between 53 and 73 years, with 42% to 57% females. The pooled rate of adverse events was 5.1% (95% CI 3.4% to 7.7%) at 24 h, 7.0% (95% CI 4.9% to 9.9%) at 72 h, 8.4% (95% CI 6.2% to 11.3%) at 7–10 days, 10.3% (95% CI 7.8% to 13.3%) at 1 month and 21.3% (95% CI 15.8% to 28.0%) at 1 year. The pooled death rate was 0.2% (95% CI 0.1% to 0.5%) at 24 h, 0.3% (95% CI 0.1% to 0.7%) at 72 h, 0.5% (95% CI 0.3% to 0.9%) at 7–10 days, 1% (95% CI 0.6% to 1.7%) at 1 month and 5.9% (95% CI 4.5% to 7.7%) at 1 year. The most common adverse event was arrhythmia, for which its rate was 3.1% (95% CI 2.0% to 4.9%) at 24 h, 4.8% (95% CI 3.5% to 6.7%) at 72 h, 5.8% (95% CI 4.2% to 7.9%) at 7–10 days, 6.9% (95% CI 5.3% to 9.1%) at 1 month and 9.9% (95% CI 5.5% to 17) at 1 year. Ventricular arrhythmia was rare. Conclusions: The risk of death or life-threatening adverse event is rare in patients presenting syncope at the ED. The most common adverse events are brady and supraventricular arrhythmias, which occur during the first 3 days. Prolonged ECG monitoring in the ED in a short stay unit with ECG monitoring facilities may, therefore, be beneficial.
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Liang Y, Li X, Tse G, Li G, Liu W, Liu T. Diagnostic value of cardiac troponin I and N-terminal pro-B-Type Natriuretic Peptide in cardiac syncope. Curr Res Physiol 2021; 4:24-28. [PMID: 34746823 PMCID: PMC8562147 DOI: 10.1016/j.crphys.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/20/2020] [Accepted: 01/27/2021] [Indexed: 11/18/2022] Open
Abstract
Objective The study aims to evaluate the diagnostic accuracy of Cardiac Troponin I(cTnI) and N-terminal pro-B-Type Natriuretic Peptide (NT-proBNP) for identifying patients with cardiac syncope. Methods This is a prospective, single-center cohort study of patients presenting with syncope hospitalized from June 21,2018 to May 30, 2019. The Evaluation of Guidelines in Syncope Study (EGSYS), a syncope-specific diagnostic score, was used for diagnostic comparator. Results A total of 118 patients were enrolled (mean age: 69.1 ± 12.3 years, 40% female). Compared to patients with reflex, orthostatic, or unexplained syncope, patients adjudicated to have cardiac syncope showed significantly higher cTnI and NT-proBNP plasma concentrations (p < 0.001 for each comparison). The area under the curve (AUC) of cTnI and NT-proBNP were moderate-to-good [0.77–0.78; 95% confidence interval (CI) 0.66–0.86], and was similar to that of EGSYS (0.71, 95%CI 0.60–0.80). Incorporation of cTnI and/or NT-proBNP into the existing EGSYS score significantly improved the diagnostic accuracy (EGSYS + cTnI: AUC 0.83; 95%CI 0.74–0.90; EGSYS + NT-proBNP: AUC 0.81; 95%CI 0.71–0.89; EGSYS + cTnI + NT-proBNP: AUC 0.83; 95%CI 0.73–0.90). Conclusions The cTnI and NT-proBNP levels were significantly higher in patients adjudicated to have cardiac syncope and the addition of both biomarkers to the EGSYS score significantly improved the diagnostic value for cardiac syncope. CTnI and NT-proBNP levels were significantly higher in patients adjudicated to have cardiac syncope. Firstly incorporation of cTnI and NT-proBNP to the EGSYS score, which significantly improved the diagnosis value. Incorporation of both biomarkers to the EGSYS score significantly improved its predictive performance.
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Affiliation(s)
- Yan Liang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China
| | - Xiulian Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China
- Corresponding author.
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China
| | - Wenling Liu
- Heart Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China
- Corresponding author. Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, No. 23, Pingjiang Road, Hexi District, Tianjin, 300211, People's Republic of China.
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Thiruganasambandamoorthy V, Yan JW, Rowe BH, Mercier É, Le Sage N, Hegdekar M, Finlayson A, Huang P, Mohammad H, Mukarram M, Nguyen PAI, Syed S, McRae AD, Nemnom MJ, Taljaard M, Silviotti MLA. Personalised risk prediction following emergency department assessment for syncope. Emerg Med J 2021; 39:501-507. [PMID: 34740890 DOI: 10.1136/emermed-2020-211095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 09/26/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Published risk tools do not provide possible management options for syncope in the emergency department (ED). Using the 30-day observed risk estimates based on the Canadian Syncope Risk Score (CSRS), we developed personalised risk prediction to guide management decisions. METHODS We pooled previously reported data from two large cohort studies, the CSRS derivation and validation cohorts, that prospectively enrolled adults (≥16 years) with syncope at 11 Canadian EDs between 2010 and 2018. Using this larger cohort, we calculated the CSRS calibration and discrimination, and determined with greater precision than in previous studies the 30-day risk of adjudicated serious outcomes not identified during the index ED evaluation depending on the CSRS and the risk category. Based on these findings, we developed an on-line calculator and pictorial decision aids. RESULTS 8233 patients were included of whom 295 (3.6%, 95% CI 3.2% to 4.0%) experienced 30-day serious outcomes. The calibration slope was 1.0, and the area under the curve was 0.88 (95% CI 0.87 to 0.91). The observed risk increased from 0.3% (95% CI 0.2% to 0.5%) in the very-low-risk group (CSRS -3 to -2) to 42.7% (95% CI 35.0% to 50.7%), in the very-high-risk (CSRS≥+6) group (Cochrane-Armitage trend test p<0.001). Among the very-low and low-risk patients (score -3 to 0), ≤1.0% had any serious outcome, there was one death due to sepsis and none suffered a ventricular arrhythmia. Among the medium-risk patients (score +1 to+3), 7.8% had serious outcomes, with <1% death, and a serious outcome was present in >20% of high/very-high-risk patients (score +4 to+11) including 4%-6% deaths. The online calculator and the pictorial aids can be found at: https://teamvenk.com/csrs CONCLUSIONS: 30-day observed risk estimates from a large cohort of patients can be obtained for management decision-making. Our work suggests very-low-risk and low-risk patients may be discharged, discussion with patients regarding investigations and disposition are needed for medium-risk patients, and high-risk patients should be hospitalised. The online calculator, accompanied by pictorial decision aids for the CSRS, may assist in discussion with patients.
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Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Éric Mercier
- Department of Family Medicine and Emergency Medicine, Universite Laval Faculte de Medecine, Quebec, Quebec, Canada.,CHU de Québec-Université Laval Research Centre, CHU de Quebec-Universite Laval, Quebec City, Quebec, Canada
| | - Natalie Le Sage
- Department of Family Medicine and Emergency Medicine, Universite Laval Faculte de Medecine, Quebec, Quebec, Canada.,CHU de Québec-Université Laval Research Centre, CHU de Quebec-Universite Laval, Quebec City, Quebec, Canada
| | - Mona Hegdekar
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anne Finlayson
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Paul Huang
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Hassan Mohammad
- Faculty of Technology and Trades, Algonquin College, Ottawa, Ontario, Canada
| | - Muhammad Mukarram
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Phuong Anh Iris Nguyen
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shahbaz Syed
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, and Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Marco LA Silviotti
- Departments of Emergency Medicine and Biomedical, and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
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Ling L, Feng T, Xue X, Ling Z. Etiology, risk factors, and prognosis of patients with syncope: A single-center analysis. Ann Noninvasive Electrocardiol 2021; 26:e12891. [PMID: 34582604 PMCID: PMC8588369 DOI: 10.1111/anec.12891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/03/2021] [Accepted: 08/21/2021] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE To investigate the main causes, risk factors, and prognosis of patients hospitalized with syncope. METHODS The patients admitted due to syncope were included. We analyzed the etiology, risk factors, and prognosis of patients with an average follow-up of 15.3 months. RESULTS High-risk factors for cardiogenic syncope included age ≥60, male, hypertension, palpitation, troponin T-positive, abnormal ECG, CHD history, and syncope-related trauma. Mortality rate was 4.6%, recurrence rate of syncope was 10.5%, and the rehospitalization rate was 8.5%. Univariate analysis showed that prognosis of syncope was related to age ≥60 years old, hypertension, positive troponin T, abnormal electrocardiogram, and coronary heart disease (p < .05). Multivariate Cox proportional hazard analysis showed that age ≥60 years old (p = .021) and high-sensitivity troponin-positive (p = .024) were strongly related to the prognosis of syncope. Kaplan-Meier curve showed statistical difference in the survival rate between the groups divided by age ≥60 years (p = .028), hs-TnT-positive (p < .001), abnormal ECG (p = .027), and history of CHD (p = .020). CONCLUSION High-risk factors for cardiogenic syncope included age ≥60, male, hypertension, palpitation, troponin T-positive, abnormal ECG, CHD family history, and syncope-related trauma. Age, hypertension, troponin T-positive, abnormal ECG, and CHD history were associated with the prognosis of syncope.
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Affiliation(s)
- Lin Ling
- Department of Cardiovascular, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Tingting Feng
- Department of Infection, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaofeng Xue
- Department of Surgical Medicine, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zicheng Ling
- Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Can I Send This Syncope Patient Home From the Emergency Department? J Emerg Med 2021; 61:801-809. [PMID: 34535304 DOI: 10.1016/j.jemermed.2021.07.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/18/2021] [Accepted: 07/25/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Syncope is a common presentation to the emergency department (ED). A significant minority of these patients have potentially life-threatening pathology. Reliably identifying that patients require hospital admission for further workup and intervention is imperative. CLINICAL QUESTION In patients who present with syncope, is there a reliable decision tool that clinicians can use to predict the risk of adverse outcome and determine who may be appropriate for discharge? EVIDENCE REVIEW Four articles were reviewed. The first retrospective study found no difference in mortality or adverse events in patients admitted for further evaluation rather than discharged home with primary care follow-up. The next two articles examined the derivation and validation of the Canadian Syncope Risk Score (CSRS). After validation with an admission threshold score of -1, the sensitivity and specificity of the CSRS was 97.8% (95% confidence interval [CI] 93.8-99.6%) and 44.3% (95% CI 42.7-45.9%), respectively. The last article looked at the derivation of the FAINT score, a recently developed score to risk stratify syncope patients. A FAINT score of ≥ 1 (any score 1 or higher should be admitted) had a sensitivity of 96.7% (95% CI 92.9-98.8%) and specificity 22.2% (95% CI 20.7-23.8%). CONCLUSIONS Syncope remains a difficult chief symptom to disposition from the ED. The CSRS is modestly effective at establishing a low probability of actionable disease or need for intervention. However, CSRS might not reduce unnecessary hospitalizations. The FAINT score has yet to undergo validation; however, the initial derivation study offers less diagnostic accuracy compared with the CSRS.
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Shimoni Z, Froom P, Benbassat J. Value of Troponin in Predicting Hospital Mortality of Older Adult Patients without Suspected Acute Coronary Syndromes. South Med J 2021; 114:603-606. [PMID: 34480195 DOI: 10.14423/smj.0000000000001287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Some authors have recommended troponin measurement to stratify patient mortality risk, but it is unclear whether troponin values add to age and routine admission laboratory tests in the prediction of in-hospital mortality of older adult patients without suspected acute coronary syndrome (ACS). The aim of our study was to determine whether troponin testing adds significantly to routine admission laboratory testing in predicting in-hospital mortality in patients without a suspected ACS. METHODS In 2018-2019, we reviewed all acutely admitted patients aged 60 years or older to Internal Medicine wards of a regional hospital after excluding those admitted to intensive care or with chest pain. The independent variables were troponin, age, sex, and routine admission laboratory tests. The outcome measure was in-hospital mortality. We compared c-statistics and the observed 10% to 90% risk gradients using logistic regression models for age and routine laboratory testing before and after the addition of troponin. RESULTS The mortality risk gradient for age and admission laboratory tests was 0.2% to 29.5%. Adding troponin did not increase the gradient significantly (0.2%-34.6%, P = 0.170), and the 95% confidence intervals for the c-statistics overlapped, increasing from 0.845 (0.818-0.876) to 0.866 (0.839-0.892). CONCLUSIONS In older adult patients without suspected ACS, troponin testing did not improve the prediction of hospital mortality above that of a model including age and common admission blood tests. In the absence of suspected ACS, troponin testing is not needed to predict the hospital mortality of older adult patients.
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Affiliation(s)
- Zvi Shimoni
- From the Departments of Internal Medicine B and Clinical Utility, Laniado Hospital, Netanya, Israel, and the Department of Medicine (retired), Hadassah University Hospital, Jerusalem, Israel
| | - Paul Froom
- From the Departments of Internal Medicine B and Clinical Utility, Laniado Hospital, Netanya, Israel, and the Department of Medicine (retired), Hadassah University Hospital, Jerusalem, Israel
| | - Jochanan Benbassat
- From the Departments of Internal Medicine B and Clinical Utility, Laniado Hospital, Netanya, Israel, and the Department of Medicine (retired), Hadassah University Hospital, Jerusalem, Israel
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Abstract
ABSTRACT Syncope is a common medical presentation that can cost the US healthcare system up to $2.4 billion dollars annually. Much of this cost can be mitigated with proper evaluation and management in the urgent care setting, as well as appropriate use of a risk stratification system.
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Affiliation(s)
- Brandon Geer
- Brandon Geer is an urgent care NP at United Memorial Medical Center Urgent Care, Batavia, N.Y
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31
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Solbiati M, Talerico G, Villa P, Dipaola F, Furlan R, Furlan L, Fiorelli EM, Rabajoli F, Casagranda I, Cazzola K, Ramuscello S, Vicenzi A, Casazza G, Costantino G. Multicentre external validation of the Canadian Syncope Risk Score to predict adverse events and comparison with clinical judgement. Emerg Med J 2021; 38:701-706. [PMID: 34039646 DOI: 10.1136/emermed-2020-210579] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 05/17/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The Canadian Syncope Risk Score (CSRS) has been proposed for syncope risk stratification in the emergency department (ED). The aim of this study is to perform an external multicenter validation of the CSRS and to compare it with clinical judgement. METHODS Using patients previously included in the SyMoNE database, we enrolled subjects older than 18 years who presented reporting syncope at the ED. For each patient, we estimated the CSRS and recorded the physician judgement on the patients' risk of adverse events. We performed a 30-day follow-up. RESULTS From 1 September 2015 to 28 February 2017, we enrolled 345 patients; the median age was 71 years (IQR 51-81), 174 (50%) were men and 29% were hospitalised. Serious adverse events occurred in 43 (12%) of the patients within 30 days. The area under the curve of the CSRS and clinical judgement was 0.75 (95% CI 0.68 to 0.81) and 0.68 (95% CI 0.61 to 0.74), respectively. The risk of adverse events of patients at low risk according to the CSRS and clinical judgement was 6.7% and 2%, with a sensitivity of 70% (95% CI 54% to 83%) and 95% (95% CI 84% to 99%), respectively. CONCLUSION This study represents the first validation analysis of CSRS outside Canada. The overall predictive accuracy of the CSRS is similar to the clinical judgement. However, patients at low risk according to clinical judgement had a lower incidence of adverse events as compared with patients at low risk according to the CSRS. Further studies showing that the adoption of the CSRS improve patients' outcomes is warranted before its widespread implementation.
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Affiliation(s)
- Monica Solbiati
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.,Dipartimento di Scienze Cliniche e di Comunita, Universita degli Studi di Milano, Milano, Italy
| | | | - Paolo Villa
- UOC Medicina d'Urgenza e Pronto Soccorso, Ospedale Luigi Sacco, Milano, Italy
| | - Franca Dipaola
- Department of Biomedical Sciences, Humanitas University IRCCS- Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Raffaello Furlan
- Department of Biomedical Sciences, Humanitas University IRCCS- Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Ludovico Furlan
- UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | | | | | | | | | - Andrea Vicenzi
- UOC Medicina d'Urgenza e Pronto Soccorso, Ospedale Luigi Sacco, Milano, Italy
| | | | - Giorgio Costantino
- Dipartimento di Scienze Cliniche e di Comunita, Universita degli Studi di Milano, Milano, Italy .,UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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A Rational Evaluation of the Syncope Patient: Optimizing the Emergency Department Visit. ACTA ACUST UNITED AC 2021; 57:medicina57060514. [PMID: 34064050 PMCID: PMC8224075 DOI: 10.3390/medicina57060514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 12/13/2022]
Abstract
Syncope accounts for up to 2% of emergency department visits and results in the hospitalization of 12–86% of patients. There is often a low diagnostic yield, with up to 50% of hospitalized patients being discharged with no clear diagnosis. We will outline a structured approach to the syncope patient in the emergency department, highlighting the evidence supporting the role of clinical judgement and the initial electrocardiogram (ECG) in making the preliminary diagnosis and in safely identifying the patients at low risk of short- and long-term adverse events or admitting the patient if likely to benefit from urgent intervention. Clinical decision tools and additional testing may aid in further stratifying patients and may guide disposition. While hospital admission does not seem to offer additional mortality benefit, the efficient utilization of outpatient testing may provide similar diagnostic yield, preventing unnecessary hospitalizations.
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Sweanor RAL, Redelmeier RJ, Simel DL, Albassam OT, Shadowitz S, Etchells EE. Multivariable risk scores for predicting short-term outcomes for emergency department patients with unexplained syncope: A systematic review. Acad Emerg Med 2021; 28:502-510. [PMID: 33382159 DOI: 10.1111/acem.14203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Emergency department (ED) patients with unexplained syncope are at risk of experiencing an adverse event within 30 days. Our objective was to systematically review the accuracy of multivariate risk stratification scores for identifying adult syncope patients at high and low risk of an adverse event over the next 30 days. METHODS We conducted a systematic review of electronic databases (MEDLINE, Cochrane, Embase, and CINAHL) from database creation until May 2020. We sought studies evaluating prediction scores of adults presenting to an ED with syncope. We included studies that followed patients for up to 30 days to identify adverse events such as death, myocardial infarction, stroke, or cardiac surgery. We only included studies with a blinded comparison between baseline clinical features and adverse events. We calculated likelihood ratios and confidence intervals (CIs). RESULTS We screened 13,788 abstracts. We included 17 studies evaluating nine risk stratification scores on 24,234 patient visits, where 7.5% (95% CI = 5.3% to 10%) experienced an adverse event. A Canadian Syncope Risk Score (CSRS) of 4 or more was associated with a high likelihood of an adverse event (LRscore≥4 = 11, 95% CI = 8.9 to 14). A CSRS of 0 or less (LRscore≤0 = 0.10, 95% CI = 0.07 to 0.20) was associated with a low likelihood of an adverse event. Other risk scores were not validated on an independent sample, had low positive likelihood ratios for identifying patients at high risk, or had high negative likelihood ratios for identifying patients at low risk. CONCLUSION Many risk stratification scores are not validated or not sufficiently accurate for clinical use. The CSRS is an accurate validated prediction score for ED patients with unexplained syncope. Its impact on clinical decision making, admission rates, cost, or outcomes of care is not known.
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Affiliation(s)
| | - Robert J. Redelmeier
- Department of Medicine University of Toronto Toronto Ontario Canada
- Department of Medicine Sunnybrook Health Science Centre University of Toronto Toronto Ontario Canada
| | - David L. Simel
- Division of General Internal Medicine Duke Veterans Affairs Medical Center Durham North Carolina USA
- Duke University Durham North Carolina USA
| | - Omar T. Albassam
- Department of Medicine University of Toronto Toronto Ontario Canada
- Department of Medicine Sunnybrook Health Science Centre University of Toronto Toronto Ontario Canada
- Division of Cardiology King Abdulaziz University HospitalKing Abdulaziz University Jeddah Saudi Arabia
| | - Steven Shadowitz
- Department of Medicine University of Toronto Toronto Ontario Canada
- Department of Medicine Sunnybrook Health Science Centre University of Toronto Toronto Ontario Canada
| | - Edward E. Etchells
- Department of Medicine University of Toronto Toronto Ontario Canada
- Department of Medicine Sunnybrook Health Science Centre University of Toronto Toronto Ontario Canada
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Khoujah D, Cimino-Fiallos N. The geriatric emergency literature 2020: COVID and beyond. Am J Emerg Med 2021; 44:177-183. [PMID: 33905980 DOI: 10.1016/j.ajem.2021.04.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/14/2021] [Accepted: 04/14/2021] [Indexed: 01/11/2023] Open
Abstract
Older adults are a rapidly growing patient population with unique characteristics and health considerations. Over the past few years, emergency physicians have started to recognize the complexities and importance of Geriatric Emergency Medicine. Several noteworthy elements of their healthcare were brought to the forefront of emergency medicine because this especially vulnerable patient population was disproportionately affected by the pandemic. Clinical topics such as delirium, telehealth, end-of-life care, and elder abuse came into focus; select relevant articles are reviewed. We also highlight equally notable literature which address clinically challenging topics, such as hip fractures and syncope. Finally, articles about improving the experience of and decreasing recidivism in geriatric emergency department patients are reviewed. In short, this review article summarizes geriatric emergency medicine literature that can help you improve your practice while caring for older adults.
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Affiliation(s)
- Danya Khoujah
- Department of Emergency Medicine, Franklin Square Medical Center, Adjunct Volunteer Assistant Professor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Nicole Cimino-Fiallos
- Department of Emergency Medicine, Meritus Medical Center, US Acute Care Solutions, Hagerstown, MD, United States of America
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35
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White JL. Commentary on "Syncope in the Emergency Department: A Guide for Clinicians". J Emerg Nurs 2021; 47:208-210. [PMID: 33558075 DOI: 10.1016/j.jen.2020.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 12/22/2020] [Indexed: 11/15/2022]
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36
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El-Hussein MT, Cuncannon A. Syncope in the Emergency Department: A Guide for Clinicians. J Emerg Nurs 2020; 47:342-351. [PMID: 33317859 DOI: 10.1016/j.jen.2020.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/11/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
Syncope is a common presenting symptom to emergency departments, but its evaluation and initial management can be challenging for ED practitioners and particularly urgent in the presence of high-risk features that increase the likelihood of cardiac etiology. Even after thorough clinical evaluation, syncope may remain unexplained. In such instances, practitioners' clinical judgment and risk assessments are critical to guide further management. In this article, evidence-informed strategies are outlined to approach the diagnosis of syncope and provide an overview of syncope clinical decision rules and shared decision-making. By incorporating risk stratification and shared decision-making into syncope care, practitioners can more confidently engage patients and families in disposition decisions to organize appropriate outpatient and follow-up care, observation, or admission.
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Quinn J, Chung S, Murchland A, Casazza G, Costantino G, Solbiati M, Furlan R. Association Between US Physician Malpractice Claims Rates and Hospital Admission Rates Among Patients With Lower-Risk Syncope. JAMA Netw Open 2020; 3:e2025860. [PMID: 33320263 PMCID: PMC7739124 DOI: 10.1001/jamanetworkopen.2020.25860] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
IMPORTANCE The US Government Accountability Office has changed its estimate of the annual costs of defensive medicine, largely because it has been difficult to objectively measure its impact. Evaluating the association of malpractice claims rates with hospital admission rates and the costs of admitting patients with low-risk conditions would help to document the impact of defensive medicine. Although syncope is a concerning symptom, most patients with syncope have a low risk of adverse outcomes. However, many low-risk patients are still admitted to the hospital, with associated costs of more than $2.5 billion per year in the US. OBJECTIVE To assess whether hospital admission rates after emergency department visits among patients with lower-risk syncope are associated with state-level variations in malpractice claims rates. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of emergency department visits among patients with lower-risk syncope used deidentified data from the Clinformatics Data Mart database (Optum). Lower-risk syncope visits were defined as those with a primary diagnosis of syncope and collapse based on International Classification of Diseases, Ninth Revision, Clinical Modification code 780.2 or International Classification of Diseases, Tenth Revision, Clinical Modification code R55 that did not include another major diagnostic code for a condition requiring hospital admission (such as heart disease, cancer, or medical shock) or an inpatient hospital stay of more than 3 days. These data were linked to publicly available data from the National Practitioner Data Bank pertaining to physician malpractice claims between January 1, 2008, and December 31, 2017. The 2 data sets were linked at the state-year level. Data were analyzed from October 2, 2019, to September 12, 2020. MAIN OUTCOMES AND MEASURES The association between the rate of hospital admission after emergency department visits among patients with lower-risk syncope and the rate of physician malpractice claims was assessed at the state-year level using a state-level fixed-effects model. Standardized costs obtained from the Clinformatics Data Mart database were adjusted for inflation and expressed in 2017 US dollars using the Consumer Price Index. RESULTS Among 40 482 813 emergency department visits between 2008 and 2017, 519 724 visits (1.3%) were associated with syncope. Of those, 234 750 visits (45.2%) met the criteria for lower-risk syncope. The mean (SD) age of patients in the lower-risk cohort was 71.8 (13.5) years; 141 050 patients (60.1%) were female, and 44 115 patients (18.8%) were admitted to the hospital, representing an extra cost of $6542 per admission. The mean rate of physician malpractice claims varied from 0.27 claims per 100 000 people to 8.63 claims per 100 000 people across states and across years within states. A state-level fixed-effects regression model indicated that, for every 1 in 100 000-person increase in the physician malpractice claims rate, there was an absolute increase of 6.70% (95% CI, 4.65%-8.75%) or a relative increase of 35.6% in the hospital admission rate, which represented an additional $102 million in costs associated with this lower-risk cohort. CONCLUSIONS AND RELEVANCE In this study, increases in physician malpractice claims rates were associated with increases in hospital admission rates and substantial health care costs for patients with lower-risk syncope, and these increases are likely associated with the practice of defensive medicine.
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Affiliation(s)
- James Quinn
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Sukyung Chung
- Stanford University School of Medicine, Stanford, California
| | | | - Giovanni Casazza
- Dipartimento di Scienze Biomedichee Cliniche “L. Sacco,” Universita' degli Studi di Milano, Milano, Italy
| | - Giorgio Costantino
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Monica Solbiati
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Rafaello Furlan
- Department of Internal Medicine, Humanitas University, Rozzano, Italy
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López-Izquierdo R, del Brio-Ibañez P, Martín-Rodríguez F, Mohedano-Moriano A, Polonio-López B, Maestre-Miquel C, Viñuela A, Durantez-Fernández C, Villamor MÁC, Martín-Conty JL. Role of qSOFA and SOFA Scoring Systems for Predicting In-Hospital Risk of Deterioration in the Emergency Department. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228367. [PMID: 33198151 PMCID: PMC7698163 DOI: 10.3390/ijerph17228367] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/13/2022]
Abstract
The objective of this study was to analyze and compare the usefulness of quick sequential organ failure assessment score (qSOFA) and sequential organ failure assessment (SOFA) scores for the detection of early (two-day) mortality in patients transported by emergency medical services (EMSs) to the emergency department (ED) (infectious and non-infectious). We performed a multicentric, prospective and blinded end-point study in adults transported with high priority by ambulance from the scene to the ED with the participation of five hospitals. For each score, the area under the curve (AUC) of the receiver operating characteristic (ROC) curve was calculated. We included 870 patients in the final cohort. The median age was 70 years (IQR 54–81 years), and 338 (38.8%) of the participants were women. Two-day mortality was 8.3% (73 cases), and 20.9% of cases were of an infectious pathology. For two-day mortality, the qSOFA presented an AUC of 0.812 (95% CI: 0.75–0.87; p < 0.001) globally with a sensitivity of 84.9 (95% CI: 75.0–91.4) and a specificity of 69.4 (95% CI: 66.1–72.5), and a SOFA of 0.909 (95% CI: 0.86–0.95; p < 0.001) with sensitivity of 87.7 (95% CI: 78.2–93.4) and specificity of 80.7 (95% CI: 77.4–83.3). The qSOFA score can serve as a simple initial assessment to detect high-risk patients, and the SOFA score can be used as an advanced tool to confirm organ dysfunction.
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Affiliation(s)
- Raúl López-Izquierdo
- Emergency Department, Hospital Universitario Rio Hortega, 47012 Valladolid, Spain;
| | | | - Francisco Martín-Rodríguez
- Advanced Life Support Unit, Emergency Medical Services, Advanced Clinical Simulation Centre, Faculty of Medicine, Universidad de Valladolid, 47005 Valladolid, Spain
- Correspondence: ; Tel.: +34-686-452-313
| | - Alicia Mohedano-Moriano
- Faculty of Health Sciences, Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (B.P.-L.); (C.M.-M.); (A.V.); (C.D.-F.); (J.L.M.-C.)
| | - Begoña Polonio-López
- Faculty of Health Sciences, Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (B.P.-L.); (C.M.-M.); (A.V.); (C.D.-F.); (J.L.M.-C.)
| | - Clara Maestre-Miquel
- Faculty of Health Sciences, Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (B.P.-L.); (C.M.-M.); (A.V.); (C.D.-F.); (J.L.M.-C.)
| | - Antonio Viñuela
- Faculty of Health Sciences, Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (B.P.-L.); (C.M.-M.); (A.V.); (C.D.-F.); (J.L.M.-C.)
| | - Carlos Durantez-Fernández
- Faculty of Health Sciences, Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (B.P.-L.); (C.M.-M.); (A.V.); (C.D.-F.); (J.L.M.-C.)
| | - Miguel Á. Castro Villamor
- Advanced Clinical Simulation Centre, Faculty of Medicine, Universidad de Valladolid, 47005 Valladolid, Spain;
| | - José L. Martín-Conty
- Faculty of Health Sciences, Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (B.P.-L.); (C.M.-M.); (A.V.); (C.D.-F.); (J.L.M.-C.)
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Thiruganasambandamoorthy V, McRae AD, Rowe BH, Sivilotti MLA, Mukarram M, Nemnom MJ, Booth RA, Calder LA, Stiell IG, Wells GA, Cheng W, Taljaard M. Does N-Terminal Pro-B-Type Natriuretic Peptide Improve the Risk Stratification of Emergency Department Patients With Syncope? Ann Intern Med 2020; 172:648-655. [PMID: 32340039 DOI: 10.7326/m19-3515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Studies have reported that natriuretic peptides provide prognostic information for emergency department (ED) syncope. OBJECTIVE To evaluate whether adding N-terminal pro-B-type natriuretic peptide (NT-proBNP) to the Canadian Syncope Risk Score (CSRS) improves prediction of 30-day serious adverse events (SAEs). DESIGN Prospective cohort study. SETTING 6 EDs in 2 Canadian provinces. PARTICIPANTS 1452 adult ED patients with syncope. INTERVENTION Serum NT-proBNP was measured locally at 1 site and batch processed at a central laboratory from other sites. The concentrations were not available to treating physicians or for adjudication of outcomes. MEASUREMENTS An adjudicated composite outcome of 30-day SAEs, including death and cardiac (arrhythmic and nonarrhythmic) and noncardiac events. RESULTS Of 1452 patients enrolled, 152 (10.5% [95% CI, 9.0% to 12.1%]) had 30-day SAEs, 57 (3.9%) of which were identified after the index ED disposition. Serum NT-proBNP concentrations were significantly higher among patients with SAEs than those without them (median, 626.5 ng/L vs. 81 ng/L; P < 0.001). Adding NT-proBNP values to the CSRS did not significantly improve prognostication (c-statistic, 0.89 and 0.90; P = 0.12 for difference), regardless of SAE subgroup or whether the SAE was identified after the index ED visit. The net reclassification index shows that NT-proBNP would have correctly reclassified 3% of patients with SAEs at the expense of incorrectly reclassifying 2% of patients without SAEs. LIMITATIONS Our study was powered to detect a 3% difference in the area under the curve. The heterogeneity of outcomes and robust baseline discrimination by the CSRS will make improvements challenging. CONCLUSION Although serum NT-proBNP concentrations were generally much higher among ED patients with syncope who had a 30-day SAE, this blood test added little new information to the CSRS. Routine use of NT-proBNP for ED syncope prognostication is not recommended. PRIMARY FUNDING SOURCE Physicians' Services Incorporated Foundation, Canadian Institutes of Health Research, and The Ottawa Hospital Academic Medical Organization.
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Affiliation(s)
| | - Andrew D McRae
- University of Calgary, Calgary, Alberta, Canada (A.D.M.)
| | - Brian H Rowe
- University of Alberta, Edmonton, Alberta, Canada (B.H.R.)
| | | | | | | | - Ronald A Booth
- University of Ottawa, Ottawa, Ontario, Canada (R.A.B., G.A.W., W.C.)
| | - Lisa A Calder
- University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada (V.T., L.A.C., I.G.S.)
| | - Ian G Stiell
- University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada (V.T., L.A.C., I.G.S.)
| | - George A Wells
- University of Ottawa, Ottawa, Ontario, Canada (R.A.B., G.A.W., W.C.)
| | - Wei Cheng
- University of Ottawa, Ottawa, Ontario, Canada (R.A.B., G.A.W., W.C.)
| | - Monica Taljaard
- The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (M.T.)
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The Accuracy of Interqual Criteria in Determining the Observation versus Inpatient Status in Older Adults with Syncope. J Emerg Med 2020; 59:193-200. [PMID: 32291127 DOI: 10.1016/j.jemermed.2020.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/06/2020] [Accepted: 02/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND McKesson's InterQual criteria are widely used in hospitals to determine if patients should be classified as observation or inpatient status, but the accuracy of the criteria is unknown. OBJECTIVE We sought to determine whether InterQual criteria accurately predicted length of stay (LOS) in older patients with syncope. METHODS We conducted a secondary analysis of a cohort study of adults ≥60 years of age who had syncope. We calculated InterQual criteria and classified the patient as observation or inpatient status. Outcomes were whether LOS were less than or greater than 2 midnights. RESULTS We analyzed 2361 patients; 1227 (52.0%) patients were male and 1945 (82.8%) were white, with a mean age of 73.2 ± 9.0 years. The median LOS was 32.6 h (interquartile range 24.2-71.8). The sensitivity of InterQual criteria for LOS was 60.8% (95% confidence interval 57.9-63.6%) and the specificity was 47.8% (95% confidence interval 45.0-50.5%). CONCLUSIONS In older adults with syncope, those who met InterQual criteria for inpatient status had longer LOS compared with those who did not; however, the accuracy of the criteria to predict length of stay over 2 days is poor, with a sensitivity of 60% and a specificity of 48%. Future research should identify criteria to improve LOS prediction.
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Martín-Rodríguez F, Del Pozo Vegas C, Mohedano-Moriano A, Polonio-López B, Maestre Miquel C, Viñuela A, Durantez Fernández C, Gómez Correas J, López-Izquierdo R, Martín-Conty JL. Role of Biomarkers in the Prediction of Serious Adverse Events after Syncope in Prehospital Assessment: A Multi-Center Observational Study. J Clin Med 2020; 9:jcm9030651. [PMID: 32121225 PMCID: PMC7141384 DOI: 10.3390/jcm9030651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 12/04/2022] Open
Abstract
Syncope is defined as the nontraumatic, transient loss of awareness of rapid onset, short duration and with complete spontaneous recovery, and accounts for 1%–3% of all visits to the emergency department. The objective of this study was to evaluate the predictive capacity of the National Early Warning Score 2 (NEWS2) and prehospital lactate (pLA), individually and combined, at the prehospital level to detect patients with syncope at risk of early mortality (within 48 h) in the hospital environment. A prospective, multicenter cohort study without intervention was carried out on syncope patients aged over 18 who were given advanced life support and taken to the hospital. Our study included a total of 361 cases. Early mortality affected 21 patients (5.8%). The combined score formed by the NEWS2 and the pLA (NEWS2-L) obtained an AUC of 0.948 (95% CI: 0.88–1) and an odds ratio of 86.25 (95% CI: 11.36–645.57), which is significantly higher than that obtained by the NEWS2 or pLA in isolation (p = 0.018). The NEWS2-L can help stratify the risk in patients with syncope treated in the prehospital setting, with only the standard measurement of physiological parameters and pLA.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Advanced Clinical Simulation Center, School of Medicine, Universidad de Valladolid. Advanced Life Support Unit, Emergency Medical Services, 47005 Valladolid, Spain;
| | - Carlos Del Pozo Vegas
- Emergency Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
- Correspondence: ; Tel.: +34-659-880-090
| | - Alicia Mohedano-Moriano
- Faculty of Health Sciences. Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (C.M.M.); (A.V.); (C.D.F.); (J.G.C.); (J.L.M.-C.)
| | - Begoña Polonio-López
- Faculty of Health Sciences. Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (C.M.M.); (A.V.); (C.D.F.); (J.G.C.); (J.L.M.-C.)
| | - Clara Maestre Miquel
- Faculty of Health Sciences. Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (C.M.M.); (A.V.); (C.D.F.); (J.G.C.); (J.L.M.-C.)
| | - Antonio Viñuela
- Faculty of Health Sciences. Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (C.M.M.); (A.V.); (C.D.F.); (J.G.C.); (J.L.M.-C.)
| | - Carlos Durantez Fernández
- Faculty of Health Sciences. Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (C.M.M.); (A.V.); (C.D.F.); (J.G.C.); (J.L.M.-C.)
| | - Jesús Gómez Correas
- Faculty of Health Sciences. Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (C.M.M.); (A.V.); (C.D.F.); (J.G.C.); (J.L.M.-C.)
| | - Raúl López-Izquierdo
- Emergency Department, Hospital Universitario Rio Hortega, 47012 Valladolid, Spain;
| | - José Luis Martín-Conty
- Faculty of Health Sciences. Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain; (A.M.-M.); (C.M.M.); (A.V.); (C.D.F.); (J.G.C.); (J.L.M.-C.)
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Jones CW, Platts-Mills TF. Feeling FAINT? Watch Out for the Grizzlies. Ann Emerg Med 2020; 75:159-161. [DOI: 10.1016/j.annemergmed.2019.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Indexed: 11/27/2022]
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